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Home My WebLink AboutMattituck-Cutchogue Athletic Booster Club - Shamrock Shuffle w.. ELIZADETICI A.NEVILLE,MMC fawn 11n11,53(}95 Main Fwd TOWN CLERK P.C}.Boy 1179 Southold,Ncvl York 11971 REGISTRAR OF VITAL STATISTICS � + Fax(631)765-6145 MARRIAGE OFFICER t Telephone(631)765-1$90 RECORDS MANAGEMENT OFFICER � `� www.southoldtownny.gov FREEDOM OF INFORMATION OFFICEIL , RECEIVED OFFICE OF THE TOWN CLEF TOWN OF SOUTHOLD FEB 14 20 APPLICATION r,OR A PERMIT TO HOLD A Southold Town Clerk SPECIAL EVENT P-Iensc provideALL of the information rec ue5led below.Inconl tete a lications WILL NOT be reviewed, Date of SubmissionsI 112a Name of Event v ll (I Innl) RDC Name of Organization: IC-Ct(kG1h ` Is this allot-For-Profit Event? e o Contact's Name: Mailing Address: -o t<rCGLt kt Contact's Phone Number: Contact's Email Address: Event Location and Site Diagram: (Use additional paper if necessary) Event Date(s): _ 119' ;0" ° (Include set up and shutdown times and dates) Nature of Event: CI � ` (Please attach a detailed description to this application) � t- 100-o4-, Time Period(Hours)of Event: From Wit_____—to �ZN �3c5'O Lp Maximum Number of Expected Attendees:— _ r Specify any special requirements(i.e.road closure,police presence): Revised 8/5/1,5 A CERTIFIr-ATC r++- I nt If a Tent or other temporary structure will be used please contact the Southold Town Building Departme at 631-765-1802 Mailing Address to Send Event Permit to, y N�VVI 6C if uc'Gtr Oyo Event Fees: L�'Wq L�`'�$250 for events with less than 1000 expected attendees ; S500 for events with 1000 or more expected attendees a 4 Clean-up Fees(Can NOT be waived): $1,500.00 Clean-up for Bicycle and/or Running Special events(ONLY) $250 or more Clean-up deposit all other events P, CERTtsIFICATOF INSURANCE l2E L1IlK]. : Not less than$2,000,000 naming the Town of Southold as art additional insured. NOTE; PLEASE SSC ATTACItED REVISED pDOPT-ED TOWN r, *** , POLICY*** Additional information and requirements may be required as deemed necessary by the Town Board. :n �5e V\t'1t r I�elnn�e.tru`c�' Print name of Authorized Person filling out Signature o Authorized Person filling out application application *Upon the request by applicant,the Town Board may waive in whole or in part any of the application requirements. ti 2 Revised 3121116 2113/22,8:29 PM Google Mops Google Maps IU 31 � i :y C_�,:8s=&€sO v..irj Fdtn .�`f- €�,�tic.,..t, ,t�.. ws ..✓_i'',. _:;s,,;�,e�' a,z?i p;«:u'_.Fd 'luck r kLn ,. AD i +F E_- r 9va dxs 0:'x'2 lmft, https:flwww.google.com/mapst@41.0524636,-72.4531988,15Z �/� 1 2022 Shamrock Shuffle i Race Route: • Start on the eastern side of Tasker Park on Carroll Ave • Make a Right onto the North Road Make a Right onto Old North Road @Wesnofske Farms r • Make a Right onto Ackerly Pond Lane Make right onto Lower Road • Make Right onto Main Road to Completion at Greenport Brewery With using Carroll Ave as a start race will thin by North Road and the same when reaching the Main Road utilzing the shoulder of the Road 3 i g 3 I i 1 i j 1 i I 1 t ....�__ ....... vv VCLiYCKCVtY —.. wvrvvnnGe W11H THE PoucyPROVIsiDNS. .."."-...m...._._.. ._.`..-. _ AVTRORIZED REPRESENTATIVE 4"ovel'age is only extended to U.S.events and acaYiti ss. ••NOTICE TO TEXAS INSUREDS:The Insurer for gie purchasing group may riot be subject to a8 tho Insurance taws and regrtatons of the State of Texas ACORD:25(2016107) The ACORD name and logo oro registered marks of ACORD 01980.2015 ACORD CORPORATION.A I dgRts msetve3. �.. _. ,_ ,b A� CERTIFICATE OF LIABILITY INSURANCE OATE(MMJDOIYYYY) i 02/09/2022 -- IS CERTIFICATE IS ISSUED AS A MATTER OF INVORMATIUN 05NEY AND CONFERS NO HTS PO C [CATE HOLDER. THIS `ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, e HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE 1 OR PRODUCER,AND THE CERTIFICATE HOLDER, t o cort f ca e o ors an ADDITIOUL INSURED,the po cy es must ave O SURED provisions or he on orae SUBROGATION IS WAIVED subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certifleato does not confer ri hts to the coriificate holder in/lou of such endorsement s. PRODUCER CONTACT E' Mass Merchandising UnderwriUn K&K Insurance Group,Inc. 80OA26-2889 ac Na: 260-459-5105 1712 Magnavox Way AID No Ext Fort Wayne IN 46804 ADDRESS: info@Sportsinsurance-kk.com CUSTOMER ID: 4 INSURER(S)AFFORDING COVERAGE NAIC e INSURED INSURER Al. Nationwide Mutual Insurance Company 23787 Mattituck-Cutchogue Athletic Booster Club INSURER B: MOaWtucck12NY 11952 INSURER C: J A Member of the Sports,Leisure&Entertainment RPG INSURER D: INSURER E. 4 INSURER F: COVERAGES CERTIFICATE NUMBER: W02105451 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE s ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUBRINUMBER BER O CY EP POLICY LIMITS LTR �D WVD MMiDD MIDD A )( COMMERCIAL GENERALLtAwLITY X 6BRPG000OD07485200 0311312022 03/1412022 EACH OCCURRENCE $1,000,000 12:01 AM EDT 12:01 AM 'ETi Kl $1,000,000 MAGE �OCCUR PREMISES Ea Occunenco MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERALAGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PERT PRODUCTS—COMP/OP AGO $1,000,000 POLICY 1:1 PRO- LOC- PROFESSIONAL LIABILITY l s LEGAL LIAB TO PARTICIPANTS $1,000,000 OTHER &NGLE LIMIT AUTOMOaiLE LJABILrrY` Ea aaident BODILY INJURY(Per person) ANY AUTO OWNED AUTOS SCHEDULED BODILY INJURY(Par accident) ONLYAUTOS - HIRED NON-OWNED Per accident AUTOS ONLY AUTOS ONLY NOT PROVIDED WHILE IN HAWAII EACH OCCURRENCE UMBRELLALISB OCCUR AGGREGATE EXCESS LIAR CLAIMS_MADE DED RETENTION PER WO—FKERS COMPENSATION AND L STATUTE OTHER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT ANY PROPRIETORIPARTNER! YIN EL DISEASE_EA EMPLOYEE EXECUTIVE OFFICERILIEMBER EXCLUDED?(Mandatory in RH) 0 Las,desalba under DESCRIPTION E.L.DISEASE—POLICY LIMIT OF OPEFIATIONS below rA MEDICAL PAYMENTS FOR PARTICIPANTSRPG0000007485200 03113/2022 03/14/2022 PRIMARY MEDICAL 12:01 AM EDT 12:01 AM EXCESS MEDICAL $25,000 DESCRIPTION OF OPERATIONS l LOCATIONS 1 VE ,Addltlonal Remarks Schedule,may be attached If more space Is roqulred) Legal Liability to Participants(LLP)limit is a per occurrence limit. Event Name:st Patrick's Day Run Type of Event:Run Distance:5K Event Date(including ancillary events and set-up/tear-down):3/13/2022 to 3113/2022 Number of Participants:300 Event Location:Tasker Park,Carrot Ave, Southold , The certificate holder is added as an additional insured but onlyfor 1111 bill caused in whole or in art,b the acts or omissions of the named insured. CERTIFICATE HOLDER CANCELLATION FT., Of of Southold SHOULD A OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P.O.Box out THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southold,NY 11971 AUTHORIZED REPRESENTATIVE (owner/Lessor of Premises) ;overage Is only extended to U.S.events and activities. NOTICE TO TEXAS INSUREDS:The insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas 01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPGO000007485200 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization Town of Southold P.O.Box 117 Southold,NY 11971 Named Insured: Mattltuck-Cutchogue Athletic Booster Club Information required to complete this Schedule,If not shown above,will be shown in the Declarations. ry A. Section 11—Who Is An Insured is amended to include B. With respect to the insurance afforded to these as an additional insured the person(s)or o rganization(s) additional insureds,the following is added to Section III shown in the Schedule, but only with respect to liability —Limits Of Insurance: for"bodily injury", "property damage" or"personal and if coverage provided to the additional insured is required in whole or In part, by your advertising injury caused, by a contract or agreement, the most we will pay on acts or omissions or the acts or omissions of those behalf of the additional insured is the amount of acting on your behalf: Insurance: 1. In the performance of your ongoing operations;or 1. Required by the contractor agreement;or 2. in connection.with your premises owned by or 2. Available under the.applicable Limits of Insurance rented to you. shown in the Declarations; However whichever is less. 1. The insurance afforded to such additional Insured This endorsement shall not increase the applicable only applies to the extent permitted by law;and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement,the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 0413 @ Insurance Services Office,Inc.,2012 Page 1 of Rudder, Lynda From: Easton,James Sent: Monday, February 14, 2022 3:11 PM To: Rudder, Lynda Subject: RE: me abc 5k I have no objection to this event. James Easton Fire Marshal,Town of Southold JamesE@southoldtownny.gov (W) 631-765-1802 PRIVELEGED AND CONFIDENTIAL'COMMUNICATION CONFIDENTIALITY NOTICE: This electronic mail transmission is intended only for the use of the individual or entity to which it is addressed and may contain confidential information belonging to the sender which is protected by privilege. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this transmission in error, please notify the sender immediately by e-mail and delete the original message. -----Original Message----- From: Rudder, Lynda <lynda.rudder@town.southold.ny.us> Sent: Monday, February 14, 2022 9:19 AM To: Blasko, Regina <rblasko@town.southold.ny.us>; Burke,John <johnbu@southoldtownny.gov>; Doroski, Melanie <Melanie.Doroski@town.southold.ny.us>; Easton,James<jamese@southoldtownny.gov>; Flatley, Martin <mflatley@town.southold.ny.us>; Ginas,James<jginas@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Mirabelli, Melissa <melissam@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>;Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: me abc 5k Please approve/disapprove the attached and provide cost analysis,thank you 1 Rudder, Lynda From: Flatley, Martin Sent: Monday, February 14, 2022 2:55 PM To: Rudder, Lynda; Blasko, Regina; Burke,John; Doroski, Melanie; Easton,James; Ginas, James; Hagan, Damon; Mirabelli, Melissa; Norklun, Stacey; Spiro, Melissa Subject: RE: me abc 5k /attachments: ShamrockSkCA.xls I have no objections to this event being approved, my cost analysis is attached Martin Flatley, Chief of Police Town of Southold Police Department 41405 State Route 25 Peconic, N.Y. 11958 Tel: 631-765-3115 The information contained in this electronic message and any attachments to this message are intended for the exclusive use of the addressee(s) and may contain information that is privileged,confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient,you are hereby notified that any review, retransmission, conversion to hard copy, copying, reproduction, circulation, publication, dissemination or other use of, or taking of any action, or omission to take action, in reliance upon this communication by persons or entities other than the intended recipient is strictly prohibited. If you have received this communication in error, please (i) notify us immediately by telephone at 631.765.2600, (ii) return the original message and all copies to us at the address above via the U.S. Postal Service, and (iii) delete the message and any material attached thereto from any computer, disk drive, diskette, or other storage device or media. -----Original Message----- From: Rudder, Lynda <lynda.rudder@town.southold.ny.us> Sent: Monday, February 14, 2022 9:19 AM To: Blasko, Regina <rblasko@town.southold.ny.us>; Burke,John<johnbu@southoldtownny.gov>; Doroski, Melanie <Melanie.Doroski@town.southold.ny.us>; Easton,James<jamese@southoldtownny.gov>; Flatley, Martin <mflatley@town.southold.ny.us>; Ginas,James<jginas@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Mirabelli, Melissa <melissam@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>; Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: me abc 5k Please approve/disapprove the attached and provide cost analysis,thank you 1 Rudder, Lynda From: Spiro, Melissa Sent: Tuesday, February 15, 2022 8:16 AM To: Rudder, Lynda Subject: RE: me abc 5k This event appears to be all on Town roads; therefore I have no comment. Melissa S. -----Original Message----- From: Rudder, Lynda Sent: Monday, February 14; 2022 9:19 AM To: Blasko, Regina <rblasko@town.southold.ny.us>; Burke,John<johnbu@southoldtownny.gov>; Doroski, Melanie <Melanie.Doroski@town..southold.ny.us>; Easton,James<jamese@southoldtownny.gov>; Flatley, Martin <mflatley@town.southold.ny.us>; Ginas,James<jginas@town.southold.ny.us>; Hagan, Damon <damonh@southoldtownny.gov>; Mirabelli, Melissa <melissam@southoldtownny.gov>; Norklun, Stacey <Stacey.Norklun@town.southold.ny.us>;Spiro, Melissa <Melissa.Spiro@town.southold.ny.us> Subject: me abc 5k Please approve/disapprove the attached and provide cost analysis,thank you L Town of Southold Police Department Special Event Cost Analysis Event: Shamrock Shuffle 5K Run Date(s): March 13, 2022 Location: Peconic Area � aoEenu Reg Hours OT Hrs jHrlYWage Total Comments :Police Officers , P.O. Ficner 3 $189.69 P.O.Jernick III 3 $200.22 S ce �afPatrol Reg Hours OT Hrs Total Comments P.O. Chenche 3 $205.08 Btc cIe Patrol. a P.O. Onufrak 3 $217.47 P.O. Flatley 3 $217.47 Marme nrts e i Reg Hours OT Hrs Hrly Wage Total Comments TC Offilcer#1 TC Officer#2 TC Officer TC Officer TC Officer gm PD Vehicles #of vehicles $/hr Total 5 $10.00 I $150.00 11 $150.00 Command Van Marine Patrol Boats Total Department Cost for Event= $1,179.93 Prepared by Chief M. Flatley 2/14/2022 Page 1 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/16/22 Receipt#: 293851 Quantity Transactions Reference Subtotal 1 Clean-Up Deposit Shamrock Shuff $1,500.00 Total Paid: $1,500.00 Notes: Payment Type Amount Paid By CK#5608 $1,500.00 Mattituck, Cutchogue Athletic Booster Cl Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Mattituck, Cutchogue Athletic Booster Club Po Box 1241 Mattituck, NY 11952 Clerk ID: LYNDAR Internal ID:Shamrock Shuff o��gUFFO�,f-�0 DENIS NONCARROW �� G.y� Town Hall,53095 Main Road TOWN CLERKp _ P.O.Box 1179 CO2 = Southold,New York 11971 REGISTRAR OF VITAL STATISTICS p _ Fax(631)765-6145 MARRIAGE OFFICER Telephone(631)765-1800 RECORDS MANAGEMENT OFFICER �Ol �a www.southoldtownny.gov FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD February 17, 2022 Jennifer Nemschick 430 Kraus Road Mattituck,NY 11952 Dear Ms. Nemschick: The Southold Town Board, at-its regular meeting held on February 15, 2022, granted permission to the Mattituck Cutchogue Athletic Booster Club to hold its Shamrock Shuffle on March 13, 2022. A certified copy of this resolution is enclosed along with the Town of Southold Policy for Special Events on town Properties and Roads. Failure to heed the policy may result in the loss of Clean-up deposit. An insurance policy naming the Town of Southold as additionally insured has been filed with this office. Applicant must comply with all executive orders of the State of New York. Please contact Captain Ginas at the Police Department, as soon as possible, to coordinate traffic control. If you have any questions please contact me at the Town Clerk's office at 631-765-1800. Good Luck with your event. Sincerely, r Lynda M Rudder Deputy Town Clerk enc Southold Town Board - Letter Board Meeting of February 15, 2022 RESOLUTION 2022-226 Item# 5.42 ADOPTED DOC ID: 17825 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2022-226 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON FEBRUARY 15,2022: RESOLVED that the Town Board of the Town of Southold hereby grants permission to Mattituck-Cutchogue Athletic Booster Club to use the following route for its 2022 Shamrock Shuffle 5K on Sunday, March 13, 2022: beginning on the eastern side of Tasker Park on Carroll Avenue, right onto County Road 48, right onto Old North Road (a,Wesnofske Farms, right onto Ackerly Pond Lane, right onto flower Road, right onto Route 25 to the finish at Greenport Brewery,provided they follow all the conditions in the Town's Policy for Special Events on Town Properties. The fees have been waived for this event with the exception of the clean-up deposit. Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Louisa P. Evans, Justice SECONDER:Brian O. Mealy, Councilman AYES: Nappa, Doroski, Mealy, Doherty, Evans, Russell Generated February 16, 2022 Page 56 Town of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/16/22 Receipt#: 293851 Quantity Transactions Reference Subtotal 1 Clean-Up Deposit Shamrock Shuff $1,500.00 Total Paid: $1,500.00 Notes: Payment Type Amount Paid By CK#5608 $1,500.00 Mattituck, Cutchogue Athletic Booster Cl Southold Town Clerk's Office 53095 Main Road, PO Box 1179 Southold, NY 11971 Name: Mattituck, Cutchogue Athletic Booster Club Po Box 1241 Mattituck, NY 11952 Clerk ID: LYNDAR Internal ID:Shamrock Shuff RESOLUTION 2022-289 Baa ADOPTED DOC ID: 17924 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2022-289 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MARCH 29, 2022: WHEREAS the following groups have supplied the Town of Southold with a refundable Clean- up Deposit fee, for their events and ` WHEREAS the Southold Town Police Chief, Martin Flatley, has informed the Town Clerk's office that this fee may be refunded, now therefor be it RESOLVED that Town Board of the Town of Southold hereby authorizes a refund be issued in the amount of the deposit made to the following Name Date Received Amount of Deposit Mattituck-Cutchogue Athletic 2/16/22 $1,500.00 Booster Club Peconic Retreat Adult Home 1/25/22 $ 250.00 Denis Noncarrow Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Greg Doroski, Councilman SECONDER:Brian O. Mealy, Councilman AYES: Nappa, Doroski, Mealy, Doherty, Evans Vendor No. Check No. Town of Southold, New York - Payment Voucher Vendor Name Vendor Address Entered by Event fee refunds Mattituck- Cutchogue Athletic Booster club POB 1241 Mattituck NY 11952 Audit Date Vendor Telephone Number Town Clerk Vendor Contact Tina C Invoice Invoice Invoice Net Purchase Order Description of Goods or Services General Ledger Fund and Account Number Number Date Total Discount Amount Claimed Number 4/2/2022 1,500.00 1,500.00 Clean up fee refund Payee Certification Department Certification The undersigned(Claimant)(Acting on behalf of the above named claimant) I hereby certify that the mater' ove specified have been received by me does hereby certify that the foregoing claim is true and correct,that no part has in good condition ithout ubstitution a services properly been paid,except as therein stated,that the balance therein stated is actually performed and that the tities ereof ha en ver' with the exceptions due and owing,and that taxes from which the Town is exempt are excluded. or disc panties oted, payme ' proved. Signature Title Signature Company Name Date Titlep"_C Date